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2. Austin J Musculoskelet Disord 4(2): id1043 (2017) - Page - 02
Karaca S Austin Publishing Group
Submit your Manuscript | www.austinpublishinggroup.com
The CTS diagnosis was made by clinical examination and
electromyography in all patients. Patients unresponsive to
conservative treatment with wrist brace and anti-inflammatory
medicine had CTR surgery. Patients with at least 12 months follow-
up were included in the study. To assess the adequacy of treatment,
we asked the patients to identify any difference between preoperative
and postoperative symptoms on a visual analogue scale (VAS).
Preoperatively 0 points indicated no pain and 10 were worst pain and
postoperatively 0 points indicated absolute regression of symptoms
and 10 points indicated lack of any effect of surgical treatment. Visual
Analog Patient Satisfaction Scale (VAPSS) was used for comparison
the level of patient satisfactory from surgical procedure. 10 point
shows the highest satisfaction and 0 is the lowest or no satisfaction.
The surgeries were performed by the same surgeon using the
same technique of OCTR. Before the surgery a standard antibiotic
was used including 1gr cefazolin intravenously. LA with bupivacaine
hydrochloride (5mg/mL) and epinephrine (5μg/mL) was used
for anaesthesia in all cases in group B. The maximum dose never
exceeded 5mL.
The length of the skin incision beginning from distal wrist
crease and extending distally about 2 to 2.5cm over the carpal canal
was made. Bipolar diathermy was used for haemostasis. The flexor
retinaculum was incised until the distal end with scissors and
epineural neurolysis was performed when deemed appropriate. Skin
was closed using single sutures. A neutral-position wrist splint was
used for postoperative immobilization for two weeks. We attempted
to contact patients by searching medical records and person-
searching services.
Statistical analysis
Data analysis was performed using SPSS statistical software
version 22.0 for Windows (SPSS Inc., Chicago, USA). The data
are shown as mean ± Standard deviation for continuous variables,
median (minimum–maximum) for ordinal ones, and frequency
with percent for categorical ones. Means were compared with using
Student’s t test. Categorical comparisons were made using chi-
square test, where appropriate. P value less than 0.05 was considered
statistically significant.
Results
The mean age of the patients was 51.4 (31-78) years in Group
A and 54.4 (28-81) years in Group B. There was no statistically
significant difference between groups in terms of age (p = 0.362).
There were 38 (76%) females and 12 (24%) males in Group A, and 35
(70%) females and 15 (30%) males in Group B (p = 0.055).
There was difference between groups in terms of laterality (p =
0.01). The mean follow-up was not significantly different between two
groups 17.5 (SD 1.4) months in Group A and 18.9 (SD 2.0) months
in Group B (p = 0.062). Intraoperative complications such as nerve or
vessel injury were not observed in each group. In one diabetic patient
superficial wound infection that healed with oral antibiotic adminis
tration was observed in group B.
Preoperatively, 47 (51%) patients in Group A and 45 (90%)
patients in Group B complained of night pain. Postoperatively, there
was not a significantly difference between groups in night pain. It was
detected nine (18%) hands in Group A eight (16%) hands in Group
B (p = 0.357). The night pain complaint was not significantly reduced
after CTR in both groups (p>0.21 for both).
There was significantly different on the average time of surgery.
It was 17.9 (SD 2.1) minute in group A and 14.8 (SD 1.7) minute in
group B (P: 0.01). Also the average discharge time from hospital was
significantly different. The time was 22.4 (SD 1.9) hours in group A
and 3.6 (SD 0.9) in group B (P: 0.01). At final follow-up there were
no recurrences or new surgical exploration. Average time to return
to daily life activities and work were 10.8 (SD 1.5) and 11.2 (SD 1.3)
days, there was no statistically significant difference between groups
A and B in term of return to daily activity (P: 0.173).
Average time of surgery was significantly different between two
groups. The average time of surgery was 17.9 (SD 2.1) minute in group
A and 14.8 (SD 1.7) minute in group B (P: 0.01). At final follow-up
there were no recurrences or new surgical exploration. Average time
to return to daily life activities and work were 10.8 and 11.2 days,
there was no statistically significant difference between groups A and
B (P:0.173).
A total of 6 patients (12%) were diabetic in group A, whereas
5 (10%) were diabetic in group B (p: 0.09). Retrospectively EMG
Figure 1: Figure showing patient inclusion criteria of the study.
GROUP A GENERAL
ANAESTHESIA
GROUP B LOCAL
ANAESTHESIA
Number of participants 50 50
MEN 12 15
WOMEN 38 35
Number of hands 50 50
RIGHT 37 36
LEFT 13 14
Hand involved: dominant/
non dominant
35/15 38/12
Diabetes 6 5
Mean Age 51.4 (31-78) 54.4 (28-81)
Mean Follow up (months) 17.5 18.9
Smoking Status 9 9
EMG results moderate/
severe
21/29 24/26
Table 1: Table showing demographic data of patients included in this study.
3. Austin J Musculoskelet Disord 4(2): id1043 (2017) - Page - 03
Karaca S Austin Publishing Group
Submit your Manuscript | www.austinpublishinggroup.com
results were similar between group A and B. In group A 21 patient
was moderate and 29 patients was severe whereas 24 patients were
moderate and 26 patients was severe (P: 0.500) (Table 1).
Preoperatively, the mean VAS score was 7,9 (SD 1.2) in Group A
and significantly decreased to 2.7 (SD1.7) (p = 0.01) also at the Group
B the mean VAS score significantly decreased 8,0 (SD 1.9) to 2.9 (SD
1.1) (p = 0.01) (Figure 2). Between the groups the postoperative VAS
score was not significantly different (p = 0.112) also VAPSS score was
not significantly different (p = 0.158) (Figure 3).
Discussion
The most commonly performed surgical technique in the
treatment of CTS is relieving the median nerve via cutting the
transverse carpal ligament. Sufficient release of the carpal ligament
is essential, and there could be possible anatomic variations.
Postoperative complications, including excessive scar tissue, injury
to the palmar motor branch of the median nerve, and unsatisfactory
release, may result in an increase in the patient’s complaints [17,18].
In the present study, we did not encounter such problems in either
study group.
The learning curve of the surgical methods must be taken into
consideration when evaluating results and outcome. CTS surgery
requires proper training and experience before proficiency is reached
[19,20]. In experienced or careless hands, the outcomes for all
techniques may be similar and have low morbidity [20,21]. In our
study there was no surgical learning curve and all surgical procedures
made by experienced senior author (BS).
El Maraghy and Devereauux conducted a survey of orthopaedic
and plastic surgeons in Ontario, Canada, to identify variations in the
choice of surgical setting and anaesthesia when treating CTS [22].
Surveys were delivered to 606 orthopaedic and plastic surgeons; 75%
responded to the questionnaire. The authors found that orthopaedic
surgeons used the formal operating room for all CTR surgeries
significantly more than plastic surgeons. Also in the selection of
anaesthesia method there were significant differences between the
two specialties. Orthopaedists used regional or GA more compared
to plastic surgeons. In our Serie 68 operations were made with GA
and 73 with LA but all in operating room.
In a published literature antibiotic using rate was found 46.7%
around orthopaedic surgeons before the surgical procedure [23]. In
our study we had a standard procedure for using antibiotics. Our low
infection rate could be related with this.
GA could have more comorbidities rather than LA including
respiratory problems [24]. In our study comorbidities due to GA was
very low. This could be related with short surgical procedure time.
Discharge time from the surgery is important for the patients.
Faster discharge from the hospital will decrease the hospital costs
and will increase the patient satisfaction. In our study GA group has
a significant longer discharge time after surgery. In addition, cost is
lowered further because preoperative screening tests (blood tests,
chest X-rays and electrocardiographs) are not required within LA
[25]. Also local regulations do not require an anaesthesia nurse or
doctor for its use, economically LA is probably more cost effective
than GA. Despite these factors, there is a role for GA in extremely
anxious patients, or when additional supple-mental procedures
are anticipated or planned. This study shows that both methods of
anaesthesia are well tolerated and are of value to the hand surgeon.
An important limitation of this research was to be a retrospective
study. The retrospective character of the study implies that in
some patients the operation was done several years before the
questionnaire was completed, which could potentially affect
the outcome. However, as the period of time between CTR and
answering of the questionnaire was relatively similar between the two
groups of patients. Also that study had potential limitation: reported
complications were in-hospital. Another important limitation is: it
was not a randomized controlled trial, despite statistical corrections;
unaccounted (unobserved) factors could have biased treatment
exposure (to regional or general anaesthesia).
Conclusion
All patients had a significant resolution of CTS symptoms at
the final follow up, as assessed by the VAS and VAPSS. The main
objective of this study was to compare the results of CTR under
GA and LA. A high percentage of patients reported high levels of
satisfaction, excellent results and improvements in their quality of life
in both group. As the VAS and VAPSS were considered the primary
outcome measure, the results of our study show that the type of
anaesthesia has no effect on the results of surgical treatment of CTS.
Further prospective, controlled, high-powered, and randomized
Figure 2: Figure showing preoperative and postoperative visual analogue
score of group A and group B.
1
2
3
4
5
6
7
8
9
10
GROUP A GROUP B
VAPSS
VAPSS
Figure 3: Figure showing visual analogue patients satisfaction score of group
A and group B.